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w Applications Will Be Processed When Submitted Properly Completed. Be Sure To Sign TheApplication. <br /> APPLICATION <br /> 20 (For Non-Transferable,Revacabl'e,'and Suspendable) SEPTAGE <br /> ENVIRONMENTAL HEALTH,PERMIT f <br /> LIQUID WASTE <br /> Application is hereby made to carry on business in the-jurisdictional area of the San•Joaquin_Local Health District. . 4 r <br /> y Business Name BA) Ad d re <br /> ��_ <br /> a, Address <br /> aOwner _.- . , .. ..:.. <br /> J Firm Partners, Addresses and Telephone Numbers - -' <br /> I Emergency Telephone.No, <br /> IL Business Telephone No. <br /> Contractor Licence No. M <br /> + ' Date t <br /> �Applicants Name (Print) ,:.�.,l .� .,. . .� •';.,. -rTitie <br /> Please check Applicable Catego (1-7)and-Flil in the Required Information <br /> 1. ❑ PUMPER VEHICLE PER IT REGISTRATION (FOR EACH VEHICLE) <br /> For July 1; --June 30, 19 -- - Disposal Sites <br /> Description(Make/Yr., Color) <br /> 1 CAL. License No. CAL. License Renewal No, <br /> Serial No. <br /> Capacity Gal.,Weights & Measures No. <br /> Equipment Parking Address <br /> 2. ❑ PUMPER YARD I <br /> For July 1, June 30, 19 <br /> No. of Vehicles Stored <br /> No. of Chemical Toilets Stored <br /> 3. ❑ PERCOLATION TEST _ <br /> R.S. or R.C.E. No. <br /> R.S. or R.C.E. Name <br /> T st cation Test Date/Time <br /> 4,SANITATION PERMIT <br /> Job A``ddress/.Location I 1 <br /> Owner F r{ Address <br /> 11 SEPTIC TANK ❑ CESSPOOL ❑ LEACHING FIELD ❑ SEEPAGE PIT .13 PACKAGE PLANT <br /> aik <br /> 11 PERMANENT 11 TEMPORARY 13 NEW ❑ REPAIR OTHER <br /> rt i 9 <br /> 5. ❑ CHEMICAL TOILETS For July 11, -June 30, <br /> Type Construction Disposal Site t <br /> No.of Units Equipment Storage/Cleaning Locations) <br /> 1. <br /> 6. ❑ PACKAGE TREATMENT PLANT For July 1,-June 30, 19 <br /> - Where Certified <br /> Operator Name <br /> t Plant Location R <br /> Plant Capacity No. Units Served ' <br /> 7. -❑ LAUNDRY , For July-1,-June 30, 19-, <br /> ❑ More Than 1,000 S Ft. I <br /> SIZE: ❑ Less Than 1,000 Sq. Ft., { q <br /> ❑ DRY CLEANING,Chemicals Used/Amount/Mo. F h <br /> Hemuownerorlicensedagent'csignaturecnrtifienthofollotwing:'lcertitylhaSinfi:enerlcrma�iceatihcwcr�5or.�hichthislac;�nitisissued,lshalinojs�all <br /> in such manner as to became subject to wwkman's compensalicn law of Caliier 4` <br /> r ab-aontractih ,innatcstw-Certifi _-f:*r -^" `x :4i�rk for 1'JhiCfl tills permit i5 <br /> - Contractor's hiring o s g or, #Ctday.'c . <br /> _- employ persons sllbiect to workman's companiliIi0l,laws Gt `,, ,',�• - J �f I hereby certify that I have prepared this application and that the'�work will be done in accordance with San Joaquin C <br /> ordinances, state laws, r and regulations f the San Joaquin Local Wealth District. r 4 <br /> APPLICANT'S SIGNATU EX <br /> i <br /> FOR.DEPARTMENT USE ONLY <br /> ❑ ANNUALLY ❑ PER UNIT ❑ PER SITE ❑ EACH El January 1 &Received By January 31 ❑ July 1 &Received By July 31 - <br />�Y Fee IS Due: REMIT <br /> - + BASE a EXPLANATION BILLING REMITTANCE $ AMOUNT DUE CHECKED <br /> .. - DATE DATE REMITTED AMOUNT <br /> 87 <br /> jFEE 9 ��� ---• 4. <br /> LESS <br /> PRORATIONPLUS <br /> { r <br /> PENALTY �, <br /> Y y ' <br /> .OTHERhill <br /> !f <br /> OTHER <br /> D <br /> ` Date Receipt No, PermQ o. Issuance ate Mailed Delivered: <br /> . eceived, y <br /> APPLICANT—RETURN A L COPIES TO:f ENVIRONMENTAL HEALTH PERMIT/SERVICES 1601 E.HAZELTON E.,P.O.Box 2408 STOCKTON,CA 85291 <br /> I 1 <br />